Just two days after finalizing a regulation to make sure trans kids from low-income families can’t afford puberty blockers or hormone therapy, the Trump administration has loosed another salvo in its bitter war against transgender people’s healthcare. On Thursday, the Department of Health and Human Services published a report—authored largely by employees of right-wing advocacy groups—alleging that some hospitals are using incorrect codes to bill insurance for pediatric gender-affirming care. The report paints transgender healthcare as motivated by profit rather than medical necessity, calling the billing codes “potentially fraudulent.”
In a social media video, Vice President JD Vance announced he was referring roughly 150 healthcare organizations listed in the report to the Department of Justice for criminal investigation. The list includes over a dozen major children’s hospitals, pharmacies including Walgreens, and small doctors offices and clinics. Standing at Vance’s side, HHS Secretary RFK Jr. added that he, too, was referring the providers for investigation by his department’s inspector general.
Yet advocates of transgender healthcare describe the HHS report released Thursday as part of a larger effort to shut down care. “This report is part of a broader pattern from this administration: Using the power of government to attack science and target health care providers instead of helping families get the care they need,” says Kellan Baker, senior advisor for health policy at the Movement Advancement Project. “It’s an intimidation campaign,” adds Jennifer Levi, the director of transgender and queer rights at GLBTQ Legal Advocates & Defenders, pointing to ways the report might show up in future legal cases.
The HHS report—provocatively titled “Wolves in White Coats: How Doctors and Hospitals Pushed and Profited from the Fraud of ‘Gender Medicine‘”—lambasts doctors’ use of two diagnostic codes when prescribing puberty blockers. One of them, “precocious puberty,” is generally used to describe early-onset puberty; the report argues that it’s improper to use the same code for children delaying puberty while they take time to explore their gender identity. The other, “endocrine disorder, unspecified,” has been openly described for years by some transgender healthcare providers as a way to avoid stigmatizing or using pathologizing language like “transsexualism” or “gender identity disorder.” According to a 2021 journal article, the “endocrine disorder, unspecified” code is “often used to bill for transgender services to avoid the stigma of labeling the person as transgender, because no [gender identity disorder] is present, and/or to avoid denials of payment.”
The report frames these billing practices as a kind of fraud. And while this theory hasn’t been fully tested in the courts, two recent settlements indicate it could be a successful angle of attack in the administration’s broader project to wipe out gender-affirming care for minors. Under pressure from the Trump administration over such billing practices, at least two hospitals—Texas Children’s Hospital and Cleveland Clinic—agreed to settlements this year. Tellingly, their settlement agreements involved much more than adjusting their use of billing codes: Both hospitals agreed to stop gender-affirming treatments for minors entirely (though their states had already outlawed such treatments). They also agreed to set aside money to treat people who detransition. (Despite the heavy emphasis on a small handful of detransition stories by activists who oppose all gender transitions, years of research have found regret rates of around 1 percent among adult recipients of gender-affirming surgery, and though there’s less research on pediatric patients, the existing studies likewise indicate low regret rates.)
Though it bears the imprimatur of the federal government, much of the “Wolves in White Coats” report contains material recycled from conservative policy groups like the Manhattan Institute and anti-trans activist groups like Do No Harm. Five of its 10 authors—including former White House senior policy strategist May Mailman, a close ally of Stephen Miller and the architect of the Trump administration’s gender-related executive orders—are employees of the Independent Women’s Forum, a faux-feminist conservative advocacy group often behind anti-trans messaging strategy. Another is Quentin Van Meter, past president of an old-school religious-right group of doctors that hold anti-LGBTQ positions and call themselves, misleadingly, the American College of Pediatricians. Also on the author list is Eithan Haim, a Texas doctor who previously faced federal charges for allegedly obtaining and leaking the private information of patients who weren’t under his care. (Once Trump took office, DOJ prosecutors dropped the charges against Haim.)
The actions of one author, Center for Christian Virtue president Aaron Baer—whose group advocates “for public policy that reflects the truth of the Gospel”—immediately suggested that the report could provide political ammunition in the midterms. Shortly after its publication, Baer took to X to demand that Ohio Democratic gubernatorial candidate Amy Acton and her running mate David Pepper comment on the Ohio healthcare providers flagged in the report. (Baer’s group might see Acton as a soft target, after she made a statement last month that misgendered trans girls as “boys” while saying she supported restrictions on their sports participation.)
But beyond its political utility, this report could turn out to be significant building block for the Trump administration’s multi-pronged legal attacks on providers of gender-affirming care. Despite Vance making a grand gesture on Thursday of referring providers for DOJ investigation, the department has already been investigating whether hospitals violated federal law by promoting off-label use of puberty blockers and hormones or by improperly billing the medications. As part of those investigations, the federal government has issued sweeping subpoenas for the private information of transgender children and teens receiving gender-affirming care.
The problem for the Trump administration is that federal judges have blocked these subpoenas almost universally. Last fall in Massachusetts, for example, federal district judge Myong Joun quashed a DOJ subpoena to Boston Children’s Hospital for the medical records and personal information—including home addresses and social security numbers—of all patients who have received gender-affirming care as well as the personnel files of over a thousand employees.
“It is abundantly clear that the true purpose of issuing the subpoena is to interfere with the Commonwealth of Massachusetts’ right to protect [gender-affirming care] within its borders, to harass and intimidate BCH to stop providing such care, and to dissuade patients from seeking such care,” Joun wrote in his order. “The Government seeks all this while not offering an iota of suspicion that BCH is actually engaging in fraudulent billing practices or off-label promotion in the first instance.”
The report issued Thursday appears designed to provide that missing “iota of suspicion”—potentially to allow the Trump administration to overcome the roadblocks it’s been hitting in court. “I think that’s DOJ’s plan,” says Levi, who has been involved in efforts to fight the subpoenas.
The report also calls on private attorneys to join the Trump administration’s efforts, urging them to file lawsuits accusing gender-affirming care providers of billing fraud, and raising the possibility of cash payouts to those who do.
Over half of states have outlawed gender-affirming medical care for minors in recent years, following a coordinated campaign by right-wing and anti-LGTBQ activists. But care remains legal in many states, some of which have passed laws protecting doctors.